Thyroid storm

Thyroid Storm


mask thyroid.gif




Thyroid storm is a rare yet mortality rates reported between 10-30%

It is often presents in patients (pts) with established hyperthyroid disease (Graves' disease, toxic multinodular goiter, solitary toxic adenoma)


Precipitating Factors: Trauma, infection, DKA, CVA, PE, MI, etc.


Presentation and Diagnosis


Thyroid storm is a clinical diagnosis of a severe and exaggerated form of thyrotoxicosis.  

Look for a triad:

Extreme Fever (often >104F)

Tachycardia (can be accompanied with AFib, widened pulse pressure)

Altered Mental Status

Other findings:


Lid Lag

Proptosis/Periorbital Edema

Pretibial plaques/nodules/non-pitting edema

Goiter/Thyroid Nodules




low TSH and high free T4 and/or T3 concentrations

mild hyperglycemia, mild hypercalcemia, abnormal liver function tests, leukocytosis, or leukopenia





Supportive Care

Fever: Cooling measures and antipyretics. 

Agitation: Benzodiazepines 

Vascular instability: IV fluids


Beta Blockers:

β blockade is critical in the management of the peripheral actions of increased thyroid hormone.

Propranolol 0.5-1mg IV over 10 mins followed by redosing 1-3mg every few hours OR 60-80mg PO q4h

Alternative metoprolol, esmolol or atenolol 

Thionamides - Inhibit New Synthesis by blocking T4-to-T3 conversion

PTU for the acute treatment of life-threatening thyroid storm -

Propylthiouracil (PTU) 600-1000mg PO loading dose with 200-400mg PO q6-8h, Hepatotoxic

Methimazole for severe, but not life-threatening for a longer duration of action 

Methimazole 20-25mg PO q4-6h - longer half-life compared to PTU.

Iodines - blocks the release of pre-stored hormone, and decreases follicular transport and oxidation.

SSKI 5 drops PO q6h or Lugol’s Solution 4-8 drops PO q6-8h

Works through “Wolff-Chaikoff effect,” in which high levels of iodide will inhibit T3/T4 synthesis and release

Give AFTER antithyroid drugs, no sooner than 30-60 mins following PTU/Methimazole.

Lithium 300mg PO q6-8h - for iodine allergy or contraindication to iodine usage 


Other therapies to consider: 

Steroids (Inhibit Peripheral Conversion) Hydrocortisone 300mg IVx1 and then 100mg IV q8h or Dexamethasone 2-4mg IV q6h

Cholestyramine (4 g orally four times daily) - bile acid sequestrants to reduce enterohepatic circulation of thyroid hormone

Plasmapheresis: Offers temporary stabilization for a patient that has been unresponsive to antithyroid medications

References: EMDocs, UpToDate